“Hence it is evident that the state is a creation of nature, and that man is by nature a political animal”
Aristotle, Politics 1253a
Aristotle’s notion of the “political animal” reminds us of the fact that human beings cannot only be described as singularities, but also as a cluster of relationship dynamics. A group is a field where these dynamics come into play and are utilized in what we call group psychotherapy.
Group psychotherapy is not a single type of therapy. It is a family of psychotherapies. Almost every individual psychotherapy model has its group counterpart and there are some types of psychotherapy which are group – dedicated. The purpose of this chapter is to provide the reader with some basic information about this family of psychotherapies and with a quick overview of some important group psychotherapy subtypes. The list is not extensive, as this would be impossible to do so in a single chapter of this guidebook.
In general, today’s group therapy is defined as a type of psychotherapy where the therapist(s) and the group meet together and use the intragroup and/or the group-therapist or client-therapist interactions for the purpose of treatment. By this definition, it is generally accepted that group psychotherapy began in the early 20th century, with the works of Joseph H. Pratt, an internist who developed what he called the “class method” (1905) for tuberculosis patients. He would lead groups of 15 patients and educate them on their disease, while they provided each other with mutual comfort. The defining characteristics of this type of therapy is that there was a set of rules in order to join the group and that patients would interact with each other and with the doctor.
In its beginnings, group psychotherapy was an entirely new point of view that challenged the dyadic analyst-analysant relationship by exposing it into a greater pool of human interaction. In 1927 Trigant Burrow, an American psychiatrist and psychoanalyst, published The Group Method of Analysis and coined the term group analysis. He applied the basic analytic principle in groups, where the group was viewed as a whole and as a social constellation. Also, by being one of the first analysts to challenge the objective role of the therapist, he led the foundations for what was later referred to as intersubjectivity. In the meantime in Europe, Jacob Moreno was developing psychodrama through his Theater of Spontaneity in Vienna (see chapter on psychodrama). In 1931 he introduced group psychotherapy into the American Psychiatric Association and it is quite probable that he coined the term group psychotherapy. By the middle 30s Paul Ferdinand Schilder, an Austrian psychiatrist and psychoanalyst, was also laying the foundations of group psychotherapy; He was conducting group sessions with psychotic children in the Bellevue hospital in New York.
The development of group psychotherapy as a practical method was largely atheoretical, but nevertheless was influenced by the study of group processes. Gustav Le Bon (1841-1931) was a major initial contributor. Le Bon dealt with the idea that a group is not a mere sum of its members and individuals tend to become more primitive once they join a large group, as they lose their sense of responsibility and their behaviors and feelings become contagious. During the same period (1920) William McDougal also described this “extra” power that groups provide to the individuals in his Group Mind theory, but he was also interested in the constructive properties of a group, rather than the destructive crowd, a process he called organization.
It is self-evident that the events of WW1 provided thinkers with a field of study of human group dynamics. In this context, Sigmund Freud also studied group dynamics mostly in organized groups, such as armies (and other types). Also influenced by Le Bon, in 1921 he published Group Psychology and the Analysis of the Ego, where he highlighted that groups provide members with a sense of purpose and that individuals connect to each other through their relation to the leader, a father surrogate. Members must reduce their individuality to serve a common goal. In order to do this, they must replace their own ego ideal with that of the group. In order to re-acquire their individuality, they need to develop empathy.
A practical shift in group psychotherapy occurred during WW2. During the war, when groups were needed to alleviate distress in massive amounts of soldiers, Wilfred Bion and John Rickman organized groups of soldiers in the Northfield Military Hospital in London (1942), with the purpose of improving the soldiers’ morale. Bion, influenced by Melanie Klein’s object relations, developed a group-as-a-whole approach, where the focus was on the group’s relation to the leader. Thus, he divided group processes into 2 types: The work group, where interactions represent a mature level of functioning and the basic assumption group, where modes of cognition are more primitive. During the same period, Siegmund H. Foulkes developed the idea of the group matrix, the network of direct communications within the group. In 1947, one of the major contributors in social psychology and group psychotherapy, Kurt Lewin, coined the term group dynamics, which refers to the way in which individuals and groups interact with their changing environment.
The development of group psychotherapy in the 60s was mainly driven by financial factors; as the mental health centers in the USA were reaching their limits, group psychotherapy presented as an efficient psychotherapy method. Also, psychotherapy in general was starting to gain acceptance as a method of personal development, rather than as a diagnosis-oriented method. This situation led to a vast popularization of group therapies and many groups were being led by minimally trained or unqualified leaders.
The publication of Irvin Yalom’s Theory and Practice of Group Psychotherapy in 1970 was a major contribution towards a scientific approach. Yalom, described certain therapeutic factors which come into place within the here-and-now context of the group and studied the group process. His 11 therapeutic factors became the basis of future group psychotherapy research.
Since the 1980s, the development of brief models of psychotherapy also affected the groups. Closed-ended groups (Brabender, 1985), inpatient groups (Yalom, 1983) were developed, while short-term models for specific homogenous groups started to gain acceptance. Relational psychoanalysis was developed as an evolution of object relations theory in the 80s (Atwood, Storolow) and found application in group therapy, by utilizing the concept of intersubjectivity.
During recent years, previous models have evolved and the current trend involves research and evidence based therapy. A major effort in dealing with the long-term problem of unqualified group psychotherapy took place in 1993 with the foundation of the International Board for Certification of Group Psychotherapists within the AGPA, which requires a core curriculum to provide the Certified Group Psychotherapist title (CGP).
Nowadays, major world events such as war, trauma and immigration have influenced group and intergroup dynamics, cultural and racial compositions and arrangements and thus they have become once again a major area of study in group psychotherapy. Evidence-based group therapies have been developed for trauma, as well as numerous other conditions. Group psychotherapy is an ever-advancing field, responding to social change and science developments and it does so by viewing the world through a peculiar lens: the group.
Group Psychotherapy models – Indications
Since there are numerous models of group psychotherapy, the indications are virtually endless. Some models are indication-oriented, while others are not and can cover diverse fields, e.g. from depressive outpatients to trauma-exposed emergency service first responders.
Regardless of the model, there are some variations within group therapy that should be noted. There can be many types of groups and the configuration can depend on many factors: Time, theoretical model, goals, composition (e.g. homogenous / heterogenous), clinical application (e.g. inpatient / outpatient) and more. The major distinction for practical application is the time-limited and open-ended group. In time-limited groups, the duration of therapy can vary from 10 weeks up to 1-2 years. These groups usually do not accept new members after initiation (closed groups), have specific goals and are usually homogenous in composition. They can be groups for life issues, general medical disease, specific diagnoses, etc. Open-ended groups are usually more heterogenous and diverse, in an attempt to represent social diversity as effectively as possible. These groups are usually more explorative and less goal-oriented.
How does group psychotherapy work? This is a subject which has been extensively studied by many authors and many theories have been formulated. In this text we decided to mention Yalom’s therapeutic factors, which are some of the most commonly addressed in literature.
YALOM’S THERAPEUTIC FACTORS
1. Instillation of hope:
To create a frame of optimism increasing the belief and confidence that recovery is possible. The main goal of this factor is to engage the patients into the group process, by understanding the therapeutic potential of the group.
The understanding that patients are not alone in their problems and their thoughts, feelings and behaviors can be similar to those expressed by others.
3. Imparting information:
To educate and empower group members with important knowledge about their specific problem and about recovery. This information can be relayed in the form of psychoeducation or direct advice by the leaders, or even better, by other group members.
Altruism can be defined as a motivational state of increasing other people’s welfare, while putting your own desires in hold. Group members gain a sense of value by helping and supporting others and they learn to receive help.
5. The corrective recapitulation of the primary family group:
The group setting can be experienced as a reenactment of the primary family setting, where the dysfunctional patterns or roles one played in primary family can be identified and transformed.
6. Development of socializing techniques:
To help group members promote social skills, empathy, tolerance and other interpersonal skills.
7. Imitative behavior:
The group setting can function as a laboratory, where patients can experiment in modeling other members’ (or the leaders’) interpersonal patterns and recovery skills, with the purpose of developing more functional patterns.
8. Interpersonal learning:
The group, left alone to interact, will eventually become a model of society. This concept is defined as a social microcosm. The interpersonal interactions within the safety of the group setting encourage members to gain insight into their own interpersonal behavior, into how they experience others and into how others experience their own behavior and feelings. This learning model is facilitated through the corrective emotional experience : the combination of conceptual learning with an emotional experience and reality testing, as defined by Franz Alexander.
9. Group cohesiveness:
Cohesiveness is both a factor as well as a prerequisite for other factors to work. It consists of the concept of attractiveness (how attractive is the group to the member) and the concept of belonging, being valued and valuing others. Cohesiveness is an analog to the therapeutical relationship in individual therapy.
A release of emotion that brings new insights into behavior or situations. Catharsis is not effective without cohesiveness, which creates a safe environment and allows emotions to gain meaning and context within the group.
11. Existential factors:
The process of dealing with fundamental aspects of human existence: Responsibility, death, isolation, freedom and presence / absence of meaning.
The Interpersonal model of Group Psychotherapy
Group psychotherapy deals with interpersonal distress and its reciprocal relationship with individual psychopathology. In interpersonal group psychotherapy, every personal state becomes a group state and affects the self-fulfillment that one can receive from his/her relationships.
The core theoretical principle in interpersonal group psychotherapy is that psychological disturbance is a consequence of disturbed interpersonal relationships and is manifested in disturbed interpersonal communication (Leszcz, 1992). It is type of therapy where the main focus is the interpersonal communication between members. This model has been developed by I. Yalom and Molyn Leszcz. Its main theoretical roots lie in Harry Stack Sullivan’s interpersonal theory. In Sullivan’s theory, the self-concept relies on internalized views of significant others, reflected by their appraisal or disapproval. Early life interpersonal experiences with significant others leave a profound impact on an individual’s interpersonal life and the view of other people in interpersonal situations can be skewed, in accordance to the past. This situation, where the concept of others is dictated by past experience, is called parataxic distortion and individuals address their behavior towards the fictious personality, rather than the real one (Sullivan, 1970). This concept resembles transference and, in turn, can lead to maladaptive (or adaptive) and predictable responses and ultimately into a maladaptive interpersonal cycle.
The ultimate goal of an interpersonal group would be to bring these interactions into light in the here-and-now of the group, in order to promote interpersonal learning. The group becomes a social microcosm, where individuals come as they are. Interpersonal group therapists can understand the group process that is taking place, they are aware of transference and countertransference and can provide empathetic feedback.
Gradually, group therapists can catalyze the conversion of maladaptive interpersonal communication into adaptive, self-fulfilling relationships. Although interpersonal learning is the core therepautic factor, it requires a strong level of cohesion in order to function.
Interpersonal groups can be formed based on a vast array of characteristics (e.g. diagnostic spectrum, common life concerns or traumatic experiences, and more) and there are no strict indications. Group members usually go through preliminary interviews which sometimes could include psychometric evaluation tools. The goal of the initial evaluation is to screen and to prepare members based on principals of group formation. A good enough preparation usually has a favourable impact on group cohesion and on goal setting. Once the group is initiated, it goes through several developmental stages, where the therapists function accordingly.
In conclusion, Interpersonal Group Psychotherapy is a model where group members form therapeutic relationships in order to understand their pathogenic interpersonal behavior and beliefs and these relationships are orchestrated by the leader, who promotes this emotional communication through feedback and empathetic listening within the here and now setting of the group.
Relational group therapy
Intersubjective and relational theory examines how each side of a relationship affect each other as well as the relationship itself. The relational model is a combination of depth psychology with attention to early developmental phenomena and unconscious dynamics with sensitive attunement to the here- and -now and the mutual, reciprocal, nature of human interaction. The basic context is that the psychoanalytic data are mutually generated by therapist and patients, co- determined by their conscious and unconscious activities in reciprocally interacting subjective worlds
In relational-intersubjective model, it is essential, that the therapist has his own subjective perceptions and developmental history and these are part of his function both as a therapist and as a co-participant in the group. Group members form valid and significant insights of his personality and psychology and respond accordingly to them. Thus, is mutually activated by therapist and patient and is always to be understood and clarified as intersubjective “co- transference”. In other words, in relational group therapy, transference and countertransference always occur together.
In addition, in this kind of therapy, the “I” statements are encouraged. The therapist, always maintaining his role as conductor or facilitator, goes on self-disclosures, making an “I” statement himself and showing that he is an engaged participant in the group, generating meaningful interactions.
Group Analytic Psychotherapy
Group analysis matured from theory of group behaviour by Siegmund H. Foulkes in the first half of the 20th century. It uses theory mostly from psychoanalysis but also from system theory, developmental psychology and sociology.
Conscious and unconscious processes is unfolded both in the individual and in the whole group. Thus the core goal for individual analysis and group analysis is the same. The therapist uses psychoanalytic theory to enlighten the group members of these processes and work around possible resistance. Free association in individual psychoanalysis is comparable to the group process, the verbal and non-verbal resonance between the group members. The group members are chosen to be heterogeneous in diagnostic category (except severe psychotic, borderline or organic disorders) and demography as a wide variety in responses improves the group process. The variety increases the chance that a member will question behaviour that is part of another member’s pathology and encourage discussion and self-reflection. Groups usually consist of 6-8 members.
Support and advice among the members should be discouraged because it takes focus away from self-exploration. Members should instead respond by expressing their own associations, feelings and reactions and by doing so the other members will use the input in their own self-exploration. This allows multiple transference to occur which gives access to feelings and dynamics within the group. That material are some of the best psychic material for exploration and change in pathology and functioning.
Mentalization-based Group Therapy (MBT-G)
Mentalization theory is based on attachment theory and object relations theory (see also the chapter about individual mentalization-based therapy. Neglect in early relationships can result in a hypersentive attachment system and weaken the ability to control both affect regulation and attentional capacity. This can lead to symptoms of unstable relationships, self-harm and impulsiveness. Weakened mentalization is a core of borderline personality disorder. In recent years the indication has broadened as MBT has also shown effect in treating anti-social and narcissistic personality disorders, PTSD and anxiety disorders.
MBT-G is a dynamic form of group therapy with an aim of creating a culture where important events are subject to a collective reflection as means of practicing mentalization in all members of the group. The therapist is responsible for a reflective environment. Severe psychopathology of the patients may often lead to pseudomentalizing or chaotic emotions which are counterproductive and can quickly spread in the group if the therapist do not regain focus for the whole group. The role of the patients is to both bring up relevant experiences from their lives and to make an effort to form a relationship with the group, to attach themselves. If successful the members will not only practice mentalizing from experiences outside the group but also within the group dynamics.
Continuity between sessions is highlighted by the therapist at the beginning of each session. The past session is summarized and all members are mentioned and reminded of the purpose of the group and their own responsibility. The next step is turntaking as to who wants time to discuss interpersonal events (past and future, e.g. confronting partner). It is the responsibility of the therapist to remind the group of who have and who have not been given time during previous session. This further underscores the role and responsibility of the patients. This could be viewed as a type of limit-setting, within the holding environment of the group. During clarification of events the therapist has to be aware of polarization (e.g. subtle emotional reactions, animosity) in the group and make the group reflect and explore it when it happens. Interventions here can explore and practice mentalization within the group.
There is no golden standard of treatment duration. Most groups are open-ended and most programs treat patients for 18 to 36 months. It is not unusually to take around one year to become stable in the group and the mentalizing practice gain significant, clinical effect in decreasing self-harm, fewer hospitalizations etc.
Cognitive Group Therapy (CBT group)
Cognitive group therapy is based in CBT theory (see the CBT chapter). The therapist has a clear role of leading the content and process of the therapy. Mostly it is closed groups varying from 8 to 24 weekly sessions. Each session has a specific topic regarding learning (resembles psychoeducation) and skills training. The therapist gives lectures to the group about the topic supported by information in work books that all patients are given at the first session. After each session the patients get homework that they will present at the next session.
Sessions are further used for patients to share events and skills training. Cognitive worksheets can be used in the group to assist the patients to link current behavioral problems with the past. Common core beliefs that emerge are unworthiness and inadequacy which are of course important to counter during therapy. In the last sessions focus will be on making a relapse prevention plan. It includes trigger identification of internal triggers as ongoing negative thoughts or external triggers as anniversaries of loss or stressful events. Core skills to counteract triggers should be clearly identified together with strategies for future support before group sessions end.
Recent data has shown a clear support for group treatment with good or excellent evidence for most disorders reviewed (panic, social phobia, OCD, eating disorders, substance abuse, trauma-related disorders, breast cancer, schizophrenia, and personality disorders) and promising for others (mood, pain/somatoform, inpatient).
Meta- analytic results in comparative studies between Individual and Group Therapy, indicate no difference in outcome among the two formats. This “no difference conclusion” was confirmed for mood disorders, panic disorders, personality disorders, schizophrenia, and eating disorders. Cognitive Behavioral Group Therapy was found to be more efficient than individual CBT for weight loss in Binge Eating Disorder patients, but the formats proved equivalent regarding symptom improvement. In substance related disorders there is a large study that shows an increased likelihood of treatment completion and goal achievement for patients treated “heavily” in groups.
Although there may be some disorders where the individual format seems more promising or where the comparison shows contradictory results (e.g., specific trauma-related disorders), format equivalence is convincingly supported regarding the economic advantages (therapist time) of group therapy. 
MBT-G has not been studied in RCTs. One RCT has been initiated. A real-world study of adolescents with borderline personality disorder has shown good results on symptom reduction and decreasing self-harm. However the drop out was a bit significant as 25 of 34 finished the study.
Quote from an expert
1,500 years ago, everybody knew that the Earth was the center of the universe. 500 years ago, everybody knew that the Earth was flat. And 15 minutes ago, you knew that people were alone on this planet. Imagine what you’ll know tomorrow.
—Agent K, Men In Black, quoted by J. Scott Rutan in his article: Things I’ve learned: 45+ years of Group Psychotherapy, American Journal Of Group Psychotherapy, October 2014
Major Group Psychotherapy Societies
American Group Psychotherapy Association (AGPA) https://www.agpa.org/
International Board for Certification of Group Psychotherapists https://www.agpa.org/cgp-certification/
International Association of Group Psychotherapy and Group Processes (IAGP) https://www.iagp.com/
Group Analytic Society International https://groupanalyticsociety.co.uk/
CE material available here: https://member.agpa.org/imis/agpa/store
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